Psychoanalysis for Treatment-Resistant Depression | Seattle, WA

Fully trained psychoanalyst Dr. Cara Erkut provides psychoanalysis in the Seattle area, offering deep, insight-oriented treatment for lasting psychological change to patients throughout Seattle, Bellevue, and the greater Eastside.

Why the Same Patterns Keep Repeating

You’ve noticed it, haven’t you? The same relationship dynamic that keeps showing up with different people. The self-sabotage that kicks in right when things are going well. The anxiety that doesn’t respond to logic, no matter how many times you tell yourself there’s nothing to worry about.

Most people who come to see me have already tried other forms of therapy. They’ve learned coping skills. They understand, intellectually, what their “issues” are. And yet somehow, the same patterns keep playing out.

There’s a reason for that. The mind has layers, and the part of us that makes decisions in the moment often isn’t the part that understands our explanations.

I’m Dr. Cara Erkut. I’m both a board-certified psychiatrist and a fully trained psychoanalyst through the Seattle Psychoanalytic Society & Institute. This dual training allows me to understand the mind from multiple angles—the biological, the psychological, and the deeply personal.

What Is Psychoanalysis, Really?

Psychoanalysis has gotten a strange reputation in popular culture. The couch. The silent analyst. Years of talking about your mother. But modern psychoanalysis looks quite different from its caricature.

At its core, psychoanalysis is an intensive exploration of the patterns, beliefs, and experiences that shape how you see yourself and relate to others. It’s based on a simple but profound premise: much of what troubles us operates outside our awareness, and bringing these unconscious patterns into consciousness allows us to make different choices.

My Approach: Mentalization-Based Treatment

The psychoanalytic psychotherapy I practice draws on mentalization-based treatment (MBT), developed by Peter Fonagy and Anthony Bateman. Mentalization is the capacity to understand behavior—your own and others’—in terms of underlying mental states: thoughts, feelings, wishes, and motivations. When we lose this capacity, which often happens under stress, we become reactive rather than reflective. We misread others, we act impulsively, we get stuck in painful patterns.

MBT helps strengthen and stabilize this capacity. Research has shown significant improvements in emotional regulation, interpersonal functioning, and overall well-being—with benefits maintained years after treatment ends [4,5].

Treatment Options: Finding the Right Fit

Psychoanalytic treatment isn’t one-size-fits-all. The frequency and intensity of treatment should match your goals, your schedule, and the depth of change you’re seeking.

Treatment Type	Frequency	Duration	Best For
Psychoanalysis	3 sessions per week	Several years	Deep character change, recurring patterns, wanting to understand yourself thoroughly
Psychoanalytic Psychotherapy	Once per week	6 months	Insight-oriented work while maintaining daily routines, specific issues with psychological roots
Brief Psychoanalytic Psychotherapy	Once per week	6 months	Focused work on a specific issue; helps identify how childhood patterns may be impacting a current difficulty

During our initial consultation, we’ll discuss which approach makes the most sense for your situation. Some patients start with brief psychoanalytic psychotherapy and, if they find it helpful, later move to longer-term psychotherapy or intensive psychoanalysis.

Psychoanalysis works best when you can attend regularly over an extended period. Meaningful change takes time. If you’re looking for quick symptom relief, other approaches might be more appropriate, and I offer those too. But if you’re tired of Band-Aid solutions and ready to do deeper work, this might be what you’ve been looking for.

Who Benefits Most from Psychoanalytic Treatment

Psychoanalytic treatment isn’t the right choice for everyone. It requires a commitment of time, money, and emotional energy. But for the right person, it offers something other treatments often don’t: fundamental, lasting change.

You might benefit from psychoanalytic work if you recognize yourself in any of these descriptions:

I also work with patients who have specific diagnoses—depression, anxiety disorders, OCD, PTSD, personality disorders—but who sense that their symptoms are connected to deeper psychological patterns. For these patients, addressing only the symptoms leaves the underlying issues untouched.

What Actually Happens in Sessions

If you’ve only experienced goal-oriented therapy with worksheets and homework, psychoanalytic sessions can feel different at first. There’s no set agenda. No specific skill to practice this week.

Instead, I’ll invite you to say whatever comes to mind—what we call free association. This might include recent events, dreams, memories, thoughts about me or our work, fantasies, fears. Nothing is off-limits, and nothing is irrelevant.

My job is to listen carefully, not just to the content of what you say but to its emotional undertones, its patterns, its connections. I’ll share observations and interpretations that might help you see things differently. Sometimes I’ll be relatively quiet; sometimes we’ll have more of a dialogue.

About the couch: In traditional psychoanalysis, patients lie on a couch with the analyst seated behind them. This isn’t theater—it serves a purpose. Not being able to see my face helps some patients focus inward rather than monitoring my reactions. But it’s not required. We can work face-to-face if that feels more comfortable.

The Phases of Psychoanalytic Treatment

Psychoanalysis unfolds in distinct phases, each with its own character and therapeutic work:

The Evidence for Psychoanalytic Treatment

One criticism sometimes leveled at psychoanalysis is that it lacks research support. This is outdated. Over the past two decades, significant research has demonstrated the effectiveness of psychoanalytic treatments.

A landmark 2010 meta-analysis by Jonathan Shedler in American Psychologist found that the effect sizes for psychodynamic therapy are as large as those for other empirically supported treatments [1]. More importantly, patients who receive psychodynamic therapy continue to improve after treatment ends—unlike many other approaches where gains fade over time.

The Tavistock Adult Depression Study found that long-term psychoanalytic psychotherapy was more effective than treatment-as-usual for chronic, treatment-resistant depression—patients who had already tried and failed multiple other treatments [2].

Combining Therapy and Medication

One advantage of working with a psychiatrist who is also a psychoanalyst: I can provide integrated treatment without needing to coordinate between providers.

For some patients, medication plays an important supporting role. Depression that’s too severe can interfere with the capacity for self-reflection. Anxiety that’s overwhelming can make it hard to free associate. In these cases, medication can create the conditions that make deeper psychological work possible.

For other patients, therapy alone is the right choice. Or they may come to me already taking medications prescribed elsewhere, and we can evaluate together whether to continue, adjust, or eventually taper.

My training at Mayo Clinic and my ongoing work in medication management means I can assess these questions carefully and provide whatever combination of treatment makes sense for you.

What to Expect at Your First Visit

Our initial consultation lasts about 90 minutes. This gives us time to explore your history, your concerns, and what brings you in now.

I’ll want to understand not just your symptoms but your life story—your family, your important relationships, your work, your sense of yourself. I’ll ask about previous therapy and what was helpful or unhelpful about it. I’ll be curious about your dreams, your fantasies, the things you think about when your mind wanders.

By the end of this first meeting, I’ll share my initial impressions and discuss whether psychoanalytic treatment seems like a good fit for what you’re seeking. We’ll talk about practical matters: frequency, fees, scheduling. And if you decide to proceed, we’ll begin.

Starting psychoanalytic treatment is itself significant. It represents a commitment to knowing yourself more deeply, even when that knowledge is uncomfortable. That commitment, more than any specific technique, is what makes the work possible.

Insurance and Fees

I accept several major insurance plans for psychotherapy.

For patients paying out of pocket, my fees are $750 for the initial 90-minute consultation and $275 for standard therapy sessions. For patients in psychoanalysis meeting multiple times per week, I offer a reduced per-session rate to make intensive treatment more accessible.

I’m happy to provide superbills for out-of-network reimbursement. Many patients find that their out-of-network mental health benefits cover a significant portion of the fee.

Serving the Greater Seattle Area

My practice is centrally located and easily accessible from Seattle and the Eastside communities.

Meet Dr. Erkut

Sources & References